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RESEARCH PLAN PROPOSAL

Impact Analysis of a Nutrition and Health Education Intervention on

School going children in Jaipur City

Synopsis of Research Work

IN THE FACULTY OF SCIENCE

(HOME SCIENCE)

THE IIS UNIVERSITY, JAIPUR

SEPTEMBER 2019

Supervised by : Submitted by:

Dr. Swati Vyas Sakshi Kothari
Associate Professor Research Scholar
Department of Home Science Foods and Nutrition

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 INTRODUCTION
Childhood has been broadly entitled as a “golden age” accomplished with innocence, joy,
and freedom. The earliest years of a child’s life determine their survival and thriving in
life, and lay the foundations for their cognitive, behavioral growth and holistic
development. During this stage children are highly influenced by the environment & the
people that surround them. Children have unique dietary needs; In general they require
less food than older children and more food than younger children. In addition it is
important to consider appropriate selection of food products and food groups for proper
nutrient supply to children to ensure that the required amount of nutrients are supplied in
the diet (Brown & Jernigan, 2012).
It is during the early years that children develop the cognitive, physical, social and
emotional skills that they need to succeed in life. These early experiences are largely
determined by supportive family and community care practices, proper nutrition, health
care and learning opportunities (National Association for the Education of Young
Children- NAEYC, 2018).
According to Census 2011, India, with population of 121.1 Cr, has 13.59% (16.45 Cr) of
its population in the age group 0-6 years and 30.76% (37.24 Cr) in age group 0-14 years.
From this it can be concluded that nutrition plays a vital role in development of each
child’s adequate brain functioning, optimal learning and enhancing academic performance,
which starts in the womb itself and continues till late childhood (Children in India 2018- A
Statistical Appraisal, 2018)
Number of researches have highlighted that undernourished preschoolers have a lower IQ,
they lack socializing skills and have more behavioral problems. Their learning abilities
and concentration spans are also significantly lower than their healthy counterparts. The
surest way to ensure a child’s proper brain development is to provide a well-balanced diet
that includes all essential vitamins, minerals, and protein foods (Charlene, 2016).
Balanced diet is essential for blossoming children for physical and cognitive development,
which are important in childhood for health and well being (Kim& Kang, 2016).
The nutritional requirements of children are high in relation to their size because of the
demands for growth, in addition to requirements for body maintenance and physical
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activity. Trends in overweight and obesity in children and adolescents have become
increasingly worrying. There is substantial evidence that poor diet and poor physical
activity patterns in childhood can lead to problems that manifest later in life, particularly
in relation to heart disease, obesity, type 2 diabetes, osteoporosis and some forms of
cancer (Weichselbaum & Buttriss, 2011). Researches show that having a healthy; balanced
diet improves brain capacity, maximizes cognitive capabilities, and improves academic
performance in children. Alternatively, the researches also shows that having too much
junk food and an unhealthy diet decreases academic performance by limiting the amount
of information to the brain. The brain is able to both retain and recall on demand. The
literature also shows the danger of not having enough nutrition and the effects of food
insufficiency, which can lead to malnutrition as well as poor academic performance
(Rausch, 2013).
Nutrition Transition
Developing countries are undergoing nutrition transition due to increased economic
development and market globalization leading to rapid changes in lifestyle and dietary
habits. The nutrition transition is characterized by a shift in disease burden from under
nutrition to over nutrition-related chronic disease (Srihari et al., 2006).

Presently India is facing Dual Burden of Malnutrition, which refers to the double burden
of both under as well as over nutrition occurring simultaneously within a population.
Recent studies show that underweight or stunting can coexist with overweight and obesity.
Industrialization and urbanization have augmented rapid socio-economic, demographic,
health and nutritional transition in India. Escalating affluency and existing poverty are
behaving like two sides of the coin; the outcome of which has manifested as the dual
paradox throwing a challenge at the country’s health sector. The market liberalization has
immensely affected dietary patterns, which has spurred up the "double burden" (Giri
&Nambiar, 2016).

According to WHO, the double burden of malnutrition is characterized by the coexistence

of under nutrition along with overweight and obesity, or diet-related non-communicable
diseases, within individuals, households and populations, and across the life course.
Childhood obesity is one of the most serious public health challenges of the 21st century.
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The problem is global and is steadily affecting many low- and middle-income countries,
particularly in urban settings is increasing at an alarming rate. Moreover, the relationship
between under nutrition and overweight and obesity is more than coexistence. Reflected in
the epidemiology and supported by evidence, under nutrition early in life – and even in
utero – may predispose to overweight and non-communicable diseases such as diabetes
and heart disease later in life (WHO, 2017).
India is country in developmental transition and hence faces the dual burden of pre-
transition diseases like under nutrition and infectious diseases as well as post-transition,
lifestyle-related degenerative diseases such as obesity, diabetes, hypertension,
cardiovascular diseases and cancers. According to National Family Health Survey (NFHS-
3 2005-2006) and UNICEF Reports (2000), 46% of preschool children in India suffer from
moderate and severe grades of protein-calorie malnutrition as judged by anthropometric
indicators (Das & Bose, 2011).
In India, approximately 19% (190 million) of the growing population comprises school-
aged children of whom 30% (48 million) currently reside in urban India. A significant
increase in prevalence of overweight and obesity and micronutrient deficiencies is
observed among children belonging to middle and high-income groups (Srihari et al.,
2007).

As the transition advances, traditional diets high in complex carbohydrates and fiber are
replaced with diets high in fats and sweeteners. Physical activity levels decline and
sedentary time increases. Increased consumption of energy-dense foods and the lack of
physical activity lead to obesity and the development of numerous chronic diseases.
Obesity and related chronic diseases were once considered diseases of affluent Western
societies; however, as a country’s gross national product (GNP) increases, the burden of
obesity shifts to lower socioeconomic groups (Tzioumis & Adair, 2014).

Globally, in 2016 the number of overweight and obese children under the age of 5, is
estimated to be over 41 million. Almost half of all overweight children under 5 lived in
Asia. Overweight and obese children are likely to stay obese during adulthood too and
more likely to develop non-communicable diseases like diabetes and cardiovascular
diseases at a younger age. Overweight and obesity, as well as their related diseases, are
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largely preventable and is recommended to be prioritized. Prevention of childhood obesity
therefore needs high priority (WHO, Childhood Overweight and Obesity, 2017).

Researches have reported that prevalence of childhood over nutrition is rising in many
developing countries including India in recent decades ranging from 2.9% to 14.3% which
makes our youth vulnerable to many life- threatening consequences. Childhood is the best
time to determine the nutritional status and take action accordingly because this is the most
fertile period of one’s life when seeding of proper dietary habits and nutritional advice will
bloom throughout life improving the total health of the whole nation. Therefore, early
childhood is now recognized as a key target in the prevention of overweight and obesity,
and the knowledge that children gain at this time about food and its health benefits can
influence their dietary choices and preferences in later life. Parental attitude and their
perception about child eating behaviour helps children to inculcate correct knowledge
regarding healthy food. Changing trends of dietary habits and lack of physical exercise
force the world to face a modern era epidemic obesity. So, childhood obesity is now a
challenge of public health to combat with (Dasgupta et al., 2017).

Underweight and obesity are both among the top ten leading risk factors for the global
burden of disease. Over the last two decades chronic non-communicable diseases have
taken over the communicable diseases thereby making it as a major public health problem,
especially in the urban areas (Giri et al., 2016).

In 2010, 43 million children under five were overweight or obese, with an additional 93
million children at risk of overweight. Global prevalence of overweight or obesity
increased in all regions, from 4.2% in 1990 to 6.7% in 2010. Although the prevalence is
higher in developed countries, developing countries have greater absolute numbers of
affected children and higher relative increases. These increasing trends are projected to
continue, with 60 million children under five expected to be overweight or obese in 2020.
Prevalence of overweight and obesity was found to be highest among children who
consumed junk food on weekly basis and had habit of snacking between meals. Unhealthy
lifestyle and habits developed at young age are responsible for predisposition to adulthood
chronic diseases. It is the cumulative effect of several factors existing in the physical

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environment that are responsible for bringing in vitro (Giri et al., 2016).

The level of physical activity, its frequency, duration, intensity, type and total amount, as
well as the time spent sedentary have a major impact on health at all stages of life. There is
concern that many children spend too much time undertaking sedentary activity. This
aspect has been identified as the fourth leading risk factor for global mortality (6% of
deaths globally).Physical activity has a major impact on health at all stages of life. Among
children and young people it is particularly important to maintain energy balance by
ensuring a healthy bodyweight, for appropriate bone and muscoskeletal development, for
reducing the risk of diabetes and hypertension, and for numerous psychological and social
aspects. There is concern that many children spend too much time engaged in sedentary
activity and not enough time in being active. Overweight and obese children are not only
at risk for insulin resistance syndrome, hypertension, dyslipidemia and
hypertriglyceridemia, but also for poor micronutrient status. Reports from countries such
as the United States, Israel and Canada have shown that overweight and obese children
have a higher prevalence of iron deficiency than normal weight children and intakes of
other micronutrients such as folate, vitamin D, calcium, magnesium and vitamin E are sub-
optimal among obese children. Moreover, micronutrient deficiencies appear to be
prevalent even among non-obese, well nourished, school aged children, and are likely to
be caused by a high intake of energy-dense foods that do not contain vitamins and
minerals. Inadequate intake of micronutrients can adversely influence growth and
development, cognitive performance and increase susceptibility to infections. Overweight
and obesity are responsible for 5% of global mortality (WHO, 2009).
Causes of childhood obesity include environmental, behavioral and personal factors that
often act in combination. Environmental factors include life at home, parenting style, peer
influence and school/community setting. Behavior factors involve one’s choice of foods
and food acceptance, whereas personal factors include nutrition knowledge, which
influences an individual’s confidence in performing a particular behaviour and
overcoming barriers to that behaviour. Through nutrition education improvement in
youth’s dietary habits will reinforce beneficial long term nutrition behaviour to effectively
protect against excessive weight gain and future development of obesity related disease

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(Rolling &Hong , 2016).

Nutrition Education
Nutrition Education is basically education about food which plays an essential role in
yielding greater understanding and acquaintance of value of nutrition which in turns help
an individual in fostering a healthy lifestyle. Nutrition Education Theories may bridge the
gap between motivation for change and behavior change. Bridging the gap between
motivation and behavior change is especially important in nutrition education
interventions programs and researches have suggested that these nutrition education
programs have been successful (Kupolati, 2018).

Monalisa in 2016 conducted a research to assess the effect of nutrition education and
dietary modification on the health and nutritional status of 104 kindergarten children.
Nutrition education and dietary modification workshop of 45 minutes for 5 days a week
were intervened among the experimental group for a month whereas the controls were
kept on casual daily routine. After one month of follow-up, the second primary data
including the anthropometric and dietary changes among both the groups were noted and
compared. Number of cases taking optimal nutritional intake increased by 74% after the
trial period of one month.

Hu et al. in 2009 evaluated the impact of nutrition education promotion and healthy
dietary habits in children with four kindergartens with 1252 children randomized to the
intervention group and three with 850 children to the control group. The personal
nutritional knowledge, attitudes and dietary behaviours of the parents were investigated.
Each month, children and parents in the intervention group participated in nutrition
education activities. The main outcome measures were anthropometrics and diet-related
behaviours of the children and the nutritional knowledge and attitudes of the parents at
baseline, 6 months (mid-term) and 1 year (post-test). Baseline demographic and socio-
economic characteristics were also collected. Results indicated that the prevalence of
children’s unhealthy diet-related behaviours decreased significantly and good lifestyle
behaviours increased in the group receiving nutrition education compared with controls.
Parental eating habits and attitudes to planning their children’s diets also changed

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appreciably in the intervention group compared with the control group (P,0.05). However,
there were no statistically significant differences in children’s height, weight, height-for-
age Z-score or weight-for-age Z-score between the two groups.

Sato et al., 2016 developed a nutrition education programmeto improve children’s

chewing habits. Four kindergarten classes in Japan (150 children, aged 5-6 years) were
studied; one class received the educational program in the classroom and at home (Group
A) and three classes received the program in the classroom only (Group B). The
educational program was integrated into the classes’ daily curriculum for five weeks. It
included storytelling with large picture books, chewing consciously while eating lunch,
singing a song with gestures, and greetings before and after meals (both groups). Group A
also used a paper textbook and was provided information by the leaflet to encourage
guardians to implement the program at home. Chewing habits before and after intervention
were evaluated. Research concluded that this intervention could be used to improve
chewing habits in young children even without active involvement of their guardians.

A study was conducted to determine changes in nutrition knowledge, attitude and practice
of 8-year-old school children after receiving a nutrition education package. A total of 418
school children from urban and rural areas participated in this study. The intervention
group consisted of 237 children while 181 children who did not receive the nutrition
education package acted as controls. The nutrition education programme that was
conducted for 3 weeks comprised of a video viewing session and a comic reading session
followed by exercise questions as reinforcement for each session, and also classroom
activities. Knowledge, attitude and practice questionnaires were distributed to the children
before (pre-intervention) and after (postintervention) receiving the nutrition education
programme. A follow-up visit was conducted six months after the programme had elapsed.
The results obtained indicated that the nutrition knowledge score increased significantly in
the intervention group from 48.3±13.2 at pre-test to 54.6±16.2 in post-test and 55.0±14.3
in follow-up test (p<0.05). The nutrition attitude score also increased significantly from
68.7±15.5 at pre-intervention to 72.6±15.0 and 74.7±15.8 during post-test and follow-up
test respectively (p<0.05). However, the nutrition practice score had no significant
improvement in both groups throughout the study period. There were no significant
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changes in the control group in knowledge, attitude and practice scores at pre, post and
follow-up tests. In conclusion, this study showed that a good nutrition education
programme had a positive impact whereby better nutrition knowledge, attitude and healthy
eating habits in children were seen. It is hoped that the improvements would be sustained
throughout their lives (Talib et al., 2007).

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 Significance of Study
Industrialization and urbanization have augmented rapid socio-economic, demographic, health
and nutritional transition in India. A complex interaction of genetic, environmental and
behavioral factor has amplified over nutrition (45% overweight and 42% obesity) and related
morbidities among children in the developing countries (Giri & Nambir,2016).The International
Obesity Taskforce (IOTF) in the year 2000estimates the global prevalence of overweight and
obesity in school-aged children to be 10% (Ahmad et al., 2010). The co-morbidities of excess
weight and the impact on the healthcare system indicate that obesity is a significant public
health issue. Childhood obesity increases the risk of obesity and related morbidities during
adulthood (Goyal et al., 2010). Wide spreading obesity among young school going children
could be best tackled if the risk factors are analyzed well in advance. Therefore emphasis needs
to be laid on prevention programs targeting behavioral modifications (Singh, 2010). Parents,
health professional, teachers and other school officials need to work together to combat this
“epidemic”.
The first few years of a child's life, may be the optimal window for promoting the development
of healthy eating behaviours in children. Children's food preferences are also influenced by
availability, accessibility, and familiarity to foods as well as parental modeling. Thus, if
children are to learn to prefer and select healthy foods, they need early, positive, repeated
experiences with those foods (Birch et al., 2009). Early childhood development pertains to
physical, mental and social growth and consists of various interventions, such as those
involving the promotion of nutrition, health and mental and social development. Children
develop many food and nutrition- related attitudes, behaviours and preferences during their pre
school years. Reduced physical activity, snacking between the meals, consuming calorie dense
and nutrient deficient food, frequently eating out of house are ostensible contributors of
childhood obesity especially among affluent families. With changing physical environment the
preferences among young children have also changed. Lack of playing space, inadequate time
for sports have increased the inclination towards screen time and simultaneous reduced their
involvement in active outdoor sports. Moreover, media marketing, easy accessibility and
affordability of unhealthy food choices have influenced the food preference; thus increasing
pediatric obesity (Giri & Nambir, 2016).

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Children also learn about food by observing the eating behaviours modeled by others.
Therefore development of the family’s dietary environment plays an important role in the
health of the next generation. Parents have a strong influence on food availability and dietary
practices from infancy through to adolescence. It is crucial that both children and parents are
educated in good dietary practices when the children are in school age and good dietary habits
because of behaviours formed at this time will persist and therefore benefit children until they
fully grown. Parents and teachers play key roles in helping children to develop positive dietary
behaviours (Chuanlai , 2009). The school environment can also help to teach children about
dietary patterns and eating behaviours (Birch et al., 2009).

From this it can be interpreted that education related to Nutritional and behavioral aspect plays
a vital role in bringing about a greater awareness of the value nutrition has in adopting a healthy
lifestyle. Education is transformative, providing knowledge through instruction that first acts
upon the attitudes of a person and then goes on to influence their behavior. The earlier this
process begins, the more effective it is (Hulya et al., 2015). Parent and caregiver behaviour
related to child feeding practices should be targeted by education, prevention and intervention
efforts. Children's eating behaviours are susceptible to many external influences within their
families, schools and communities. Currently, many of these influences promote dietary
patterns that predispose to obesity. Fortunately, these influences can also act to promote healthy
dietary practices (Birch et al., 2009).

Hence, public health interventions are warranted to combat this increasing epidemic. If the
present trend of overweight/obesity continues, it may emerge as the single most important
public health problem in children (Giri & Nambir ,2016). Furthermore, the evidence base for
interventions aiming to prevent childhood obesity, particularly in community settings, is limited
(Wilson et al., 2008).

Therefore the present research has been planned with an aim to analyze impact of nutritional
and health based educational intervention on knowledge level of parents and knowledge,
attitude and practices of school age children residing in Jaipur city.

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 OBJECTIVES
• To collect information related to demographics and nutritional status of children.
• To assess Nutritional Knowledge, Attitude and Practices of caretakers and children.
• To impart need based Nutrition and Health Education Intervention based on the
Information collected.
• To assess impact of Nutrition and Health Education Intervention on both caretakers
and children.

METHODOLOGY
This chapter of study is mainly concerned with the methodological aspects pertaining to
the present investigation. The design of the study refers to the logical manner in which
units of study will be assessed and analyzed for the purpose of the drawing conclusions.
The present study will be carried out in four phases:
PHASE I- Pre Intervention Phase
A) Demographic Information
• Locale of the Study
- Area Selection
- Sample Selection
- General Information
B) Assessment of Nutritional Status
• Anthropometry Measurements
-Height
-Weight
-Weight for age
-Height for age
-Calculation of Body Mass Index
• Qualitative Assessment of Dietary Intake
-Food Frequency Questionnaire
• Morbidity Data

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 C) Development and Validation of Survey Instrument
• For Caretakers
-Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire
• For Children:
- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

PHASE II- Intervention Phase

• Designing of a Tailored Nutrition Education Intervention Campaign for Children
and Caretakers
• Implementation of campaign for 8 weeks

Phase III – Post Intervention Phase

• Impact Analysis of Nutrition Education Intervention For Caretakers
-Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire
• Impact Analysis of Nutrition Education Intervention For Children
- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

Phase IV- Follow Up Study

• For Caretakers
-Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

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 • For Children:
- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire
Phase V- Data analysis and report writing

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Research Design

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PHASE I- (Pre Intervention)
A) Demographic Information
• Locale of the study
-Area Selection
Present study will be conducted in Jaipur city. According to the information provided
by Jaipur Municipal Corporation, 2019 of Jaipur city (Rajasthan). The city has been
divided into 8 zones MotiDungri, HawaMahal, East, HawaMahal West, Vidyadhar
Nagar, Civil Line, Sanganer, Amber and Mansarovar Zone.Form this we have
shortlistied two zones 1) MotiDungri and 2) Mansarovar on the basis of convenient
sampling according to easy approachability and good connectivity. These two zones
have 19 wards in total.

• MotiDungri Zone comprises 11 wards No. 35, 38, 39, and 44 to 51.
• MansarovarZone comprises 8 wards No. 23 to 29, and 40.

Out of 19 wards we selected 5 wards purposely.We surveyed these 5 wards and prepared a
list of all government recognized schools providing education to children and shortlisted
three schools on the basis of below mentioned criteria:
Inclusion criteria
• The schools should follow English as medium of instruction.
• The schools should have coeducation system of education.
• The schools should be catering to children belonging to same socio economic status.
• Strength of students should be above 200.
• Fee structures should be above 35000 pa.
• A written consent from management for cooperation.
-Sample Selection
An interventional study will be conducted in the shortlisted schools on children aged
between 5-6 years. The school principle, teachers and parents of the students will be
approached; project objective will be explained to them. Initially group meetings and
interactive sessions will be held in order to develop good rapport with the subjects. Finally

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all those children who meet the criteria and are willing to participate will be enrolled for
study.
Inclusion criteria
• The age should be between 5-6 years.
• The subjects should be regular in school.
• Subjects should be free from morbidities.
• Subjects should cooperate and be a part of research.
• Written Consent of parents
Subjects will be asked to fill consent form before proceeding with data collection. The
data will be collected using semi-structured questionnaires, standard tools and techniques.
After shortlisting the schools and obtaining consent from management we will randomly
divide schools into control and experimental category. The sample size will consist
approximately 350 subjects, 150 in experimental category and 150 will serve as controls in
order to ensure stastical validity of results. Baseline of information will be obtained from
all the students (both control and experimental category) however the students of school
kept in control category will just receive education material to read but the students
belonging to experimental category will be enrolled in a formal 8 week Intervention
Campaign.
-General Information
The general information of the subjects will be collected by structured questionnaire
developed and pre tested which will include age, parental educational qualification,
gender, religion, per capita income, family size and type, dietary patterns etc.

B) Assessment of Nutritional Status

Three parameters will be used to evaluate the nutritional status of the children;
anthropometric measurements (weight and height) to calculate Body Mass Index (BMI),
weight for age and height for age using cutoffs suggested by WHO, 2010. Morbidity
pattern will be recorded with help of parents to obtain information about episodes of
illness and infections of past one month and Food Frequency Questionnaire (FFQ) will be
filled up to assess child’s habitual food indicate just for analyzing qualitative aspect of
food intake.
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 • Anthropometry Measurements
Anthropometry is the most direct method for the assessment of wide spread nutritional
problems in the world. Nutritional anthropometry is measurement of human body at various
ages and levels of nutritional status. It is based on the concept that an appreciable measurement
should reflect any morphological variation occurring due to a significant functional
physiological state.
Ø Weight: It is the most widely used and the simplest reproducible anthropometric
measurement. It indicates the body mass and is a composite of all body constituents like
water, minerals, fat, protein, bone etc.

Technique (Jelliffe, 1966):

A weighing balance will be used for measuring weight. The balance will be calibrated using
standard weight after taking weight of every 3rd subject. The zero error of the weighing
scale will be checked before taking the weight and corrected as required. The subject will
be asked to stand on the platform bare feet, with minimum clothing and without leaning
against or holding anything. The measurements will be taken to the nearest of 0.5 kg.

Ø Height: It is a linear measurement made up of the sum of four components, i.e., Legs,
Pelvis, Spine and Skull (Jelliffe, 1966).

Technique (Cameron et al., 1978):

The height of each subject will be measured using vertical anthropometric rod. The subject
will be asked to stand erect looking straight on a leveled surface without shoes, with heels
together and toes apart. The anthropometric rod will be placed behind the subject in the
center of the heels perpendicular to the ground in such a way that the rod passes vertically
between the buttocks touching the back of the head. The investigator stood on subject left
side and firmly held the chin of the subject with her/his left hand and the occiput with
her/his right little finger in the Frankfurt horizontal plane (an imaginary line joining the
tragus of the ear and the eye), moving the headpiece of the sagittal plane over the head of
the subject applying a slight pressure to reduce the thickness of the hair. The reading will
be noted to the nearest of 0.1 cm.

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In children the most commonly used anthropometric indices to assess their growth status are
height-for-age and weight-for-age. These anthropometric indices can be interpreted as
follows:
Ø Height for Age
Stunted growth reflects a process of failure to reach linear growth potential as a result of
suboptimal health and/or nutritional conditions. On a population basis, high levels of stunting
are associated with poor socioeconomic conditions and increased risk of frequent and early
exposure to adverse conditions such as illness and/or inappropriate feeding practices. The
worldwide variation of the prevalence of low height-for-age is considerable, ranging from
5% to 65% among the less developed countries.
Ø Weight for Age
Weight-for-age reflects body mass relative to chronological age. It is influenced by both the
height of the child (height-for-age) and his or her weight (weight-for-height), and its
composite nature makes interpretation complex. For example, weight-for-age fails to
distinguish between short children of adequate body weight and tall, thin children. However,
in the absence of significant wasting in a community, similar information is provided by
weight-for-age and height-for-age, in that both reflect the long-term health and nutritional
experience of the individual or population.
The WHO recommends the use of SD classification (WHO 1983) to categorize the children
into different grades of nutritional status. Distribution of preschool children is carried out
using WHO-MGRS reference values, as provided below:

SD Classification Weight for age Height for age

>Median-2SD Normal Normal
<Median-2SD to Moderate Stunting Moderate wasting
<Median -3SD
<Median -3SD Severe Stunting Severe Wasting
Source: Bamji et al., 2016

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 Ø Body mass index (BMI)
The Body Mass Index defines the level of adiposity according to the relation of weight to
height. It estimates the dependence on frame size. The body mass index is the relative
weight index that shows highest correlation which independent measures of body fat
(Skills, 1994).

Technique BMI (Bamji et al., 2016)

The body weight and height will be taken as described above. To obtain the body mass index,
weight in kg will be divided by square of height in meter square as given below:

Body mass index (BMI) (kg/m²) = Weight (kg)/ Height (m²)

BMI of <5thpercentile for age and gender is considered as undernourished, between 5th and
85thpercentiles as normal, between 85th and 95th percentile as overweight and more than
95thpercentile considered as obese. The age and sex specific percentile values are presented
in table below:
Category Classification

<5th percentile Undernourished

5th and 85th percentiles Overweight

95th percentile Obese

Source:WHO- Bamji et al., 2016

• Food Frequency Questionnaire for qualitative assessment of dietary intake of

children
A food frequency questionnaire will be given to the mothers of children. It will consist of given
a list of different food items to indicate his or her child’s intake (frequency and quantity). In
this list mentioned mothers will be asked to record frequency of consumption like per day, 4 to
5 times per week, 2 to 3 times per week, once a week, 2 to 3 times a month and rarely of their
child. Portion sizes are also asked by the subjects and converted to weights in grams. A FFQ is
common method used to assess individual long term dietary intake of foods and nutrients. The
questionnaire elicits a subjectivity recorded “usual frequency” of consuming an item from a list

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of foods. The recall responses will be transformed to the average nutrient intake per day using
food composition tables.

The food frequency questionnaire will contain questions about food groups (milk and dairy
products, meat and related products, vegetables, fruits, cereals, fats/desserts, and beverages) and
aims to determine the child’s food consumption status (Baysal, 2002). Those who ate a
particular food every day will be awarded 5 points, those eating it three to five times a week
will be awarded 4 points, those who ate it one to two times a week will be awarded 3 points,
those who ate it every 15 days will be awarded 2 points, those who ate the food once a month
will be awarded 1 point, while those who never ate it will be awarded 0 points. Rising scores
will indicate that the child’s food consumption is more. Parents will complete the form prior to
the education, following the education, and 1 month after the education to check the retention.

• Morbidity Data
A structured questionnaire will be formulated to be administered by parents of children
between 5-6 years of age to obtain information about common morbidity conditions like
infections, fevers , diarrhea, conjunctivitis and malaria.

The questionnaire will include similar morbidity questions related on asthma and jaundice,
fever, diarrhea along with episodes of illness and infections and acute respiratory infection,
primarily pneumonia, which is a major cause of illness among children and the leading cause of
childhood mortality throughout the world (Murray & Lopez, 1996).

C) Development and Validation of Survey Instrument

• For Caretakers
- Nutrition Knowledge Questionnaire
Knowledge is defined as the fact or condition of being aware of familiar of something and
one of the most suitable method of assessing the knowledge is by developing questionnaire
or schedules. Hence, in the present research a Nutrition Knowledge questionnaire will be
developed and validated by a team of experts. Through questionnaire we will try to evaluate
knowledge levels of subjects. It will be close ended in nature in which respondents will be
given options from which they will select appropriate answers. Each right answer will be
awarded 1 point while each wrong answer was awarded 0.
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Nutrition knowledge of caretakers will be assessed by asking questions for example:
ü Which of these foods has the most trans-fat?
a) Biscuits b) Cakes &pastries c) Burger d) Chips

ü Which is the best source of Iron?

a) Spinach b) Almond c) Jaggery d) Milk

-Attitude Questionnaire
Attitude is a mental position with regard to a fact or state. In the present research
responded attitude or personal feeling will be assessed using likerat scale in which we
will try to evaluate degree of agreement by giving them options like strongly agree,
agree, neutral, disagree and strongly disagree.
Nutrition related attitude of the caretakers will be assessed by asking questions like:

ü Do you think eating lot of carbohydrates can lead to obesity?

a) Strongly agree
b) Agree
c) Neither agree/Nor disagree
d) Disagree
e) Strongly disagree

ü Do you think green leafy vegetables are rich in protein ?

a) Strongly agree
b) Agree
c) Neither agree/Nor disagree
d) Disagree
e) Strongly disagree

-Practices Questionnaire
Practice is usual way of doing something. Nutritional practices can be assessed using
structured questionnaire as well as observational method. In the present research we
will be designing a questionnaire for assessing nutritional practices of caretakers.
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 The questionnaire will be having options never, rarely, sometimes, often, always with
scoring of 1,2,3,4, and 5 respectively. The questionnaire will be targeted to check
individuals food related practices like his/her food responsiveness, emotional
overeating, enjoyment of food, satiety responsiveness etc.

Practice related attitude of the caretakers will be assessed by asking questions like:
ü Do you pack lunchbox for your child everyday?
a) Never b) Rarely c) Sometimes d) Often e) Always

ü Do you cook green leafy vegetables thrice a week?

a) Never b) Rarely c) Sometimes d) Often e) Always

• For Children
Assessment of knowledge attitude and practices related to Nutrition and health of
children will be done.
-Nutrition Knowledge Questionnaire
It will be developed and validated in similar way as mentioned above.
Nutrition knowledge of the child will be assessed by asking questions for example:
ü Choose the food group that you should eat the MOST every day?
a) Fats b) Fruits & Vegetables c) Junk Food d) Cold Drink

ü Choose the food group that gives your body the best ENERGY?
a) Milk b) Chocolate c) Fruit d) Pizza

-Attitude Questionnaire
Nutrition related attitude of the child will be assessed by asking questions like :
ü Do you think eating lot of sweets can damage your teeth?
a) Strongly agree
b) Agree
c) Neither agree/Nor disagree
d) Disagree
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 e) Strongly disagree
ü Do you think Cold drinks contains high levels of sugar ?
a) Strongly agree
b) Agree
c) Neither agree/Nor disagree
d) Disagree
e) Strongly disagree

-Practices Questionnaire
Practice is usual way of doing something. Nutritional practices can be assessed using
structured questionnaire as well as observational method. In the present research we
will be designing a questionnaire for assessing nutritional practices of children.
The questionnaire will be having options never, rarely, sometimes, often, always
with scoring of 1,2,3,4, and 5 respectively. The questionnaire will be targeted to
check individuals food related practices like his/her food responsiveness, emotional
overeating, enjoyment of food, satiety responsiveness etc.

Practice related attitude of the child will be assessed by asking questions like:
ü Do you consume green vegetables daily?
a) Never b) Rarely c) Sometimes d) Often e) Always
ü How often do you consume breakfast ?
a) Never b) Rarely c) Sometimes d) Often e) Always

Pilot Testing: A pilot survey will be carried out to test the appropriateness on 10% of the
sample size and thereby refine the survey instruments.

PHASE II- Intervention Phase

ü Designing and Implementation of a Tailored Nutrition Education
Intervention Campaign
All intervention activity and material will be prepared specifically for the study, and
will undergo a validation process before being used in the intervention. Health
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 messages will be prepared and determined through the sessions of lectures,
discussions, demonstrations and IEC materials like power point presentations,
documentaries, charts, posters, leaflets, games, puzzles, pamphlets etc. These
messages will be focused on some nutrition topics like food groups, balanced diet,
food pyramid, importance of micronutrients, health risk related to obesity as well as
topics related to health aspects, personal hygiene, immunization and physical activity.
-Caretakers
The parents of the children will be approached through Parent Teacher meetings and
certain Nutrition Education Material will be distributed such as:
ü Healthy meal cookbooks
ü Food Demonstrations
ü Parents received weekly newsletters mirroring the children’s curriculum.
ü Interactive homework assignments between parents and children.
ü Practice of reading Nutrition Labels

-Children
The designed educational campaign will be implemented for duration of 8 weeks.
An 8-week intervention campaign will be designed for children in experimental category.
Two sessions per week will be organizes and each session will be of 60 minutes duration.
Hence the total contact hours will be 2hrs/week i.e. 16 hrs for 8 weeks.
Several activities will be organized during intervention phase based on topics related to
Nutrition Health as well as Physical activities as per the information collected through
the survey instrument.
Examples of certain activities to be organized include:
ü Drawing and coloring the favorite food
ü Fruit basket game
ü Reading stories about food
ü Completing the food pyramid puzzle (cereal and milk groups)
ü Coloring the cereal and milk groups pictures- Attaching the colored pictures to
suitable places on the food pyramid
ü Asking about the known fruit and vegetable names : Showing healthy-unhealthy
and underweight-overweight children and asking the causes
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 ü Showing a picture of a beautiful child with rotten teeth and asking about the
reasons -Asking about the foods that make bones and teeth stronger
ü Eat smart activities
• Implementation of campaign for 8 weeks
After developing a good rapport with subjects who are willing to participate in the study.
Conduction of some informal introductory classes and quiz session for a week will be done so
that they become to join the intervention sessions which will be organized in the school
premises itself once in a week. The educational talk will be conducted for 60 minutes by using
developed IEC materials. It will be followed by a 15 minute question and answer session in
which the children will be motivated to participate actively. Besides these educational sessions,
some interesting topics will be discussed as per their interest and some informal talks on comic
books, favorite cartoon characters and comedy shows will also be discussed so that they
become interested to give their full participation and this will help to build a good rapport with
them. Quiz competitions will be conducted and children who will win, they will get incentives
or prizes like wafers, chocolates, pencil, clips etc.

Phase III – Post Intervention Phase

• Impact Analysis of Nutrition Education Intervention For Parents
- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

• Impact Analysis of Nutrition Education Intervention For Children

- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

After completion of 8 weeks of intervention the impact assessment of the programme will be
done using the same Survey Instrument which was used and for assessing qualitative
improvement in dietary intake, the same food frequency questionnaire will be used which
was used initially.
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Phase IV- Follow Up Study
• Impact Analysis of Nutrition Education Intervention For Caretakers
- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

• Impact Analysis of Nutrition Education Intervention For Children

- Nutrition Knowledge Questionnaire
- Attitude Questionnaire
- Practices Questionnaire

After assessing the impact of educational intervention, follow up study will be taken up after 1
month for checking the sustainability of the intervention program using same Survey
Instrument designed for both caretakers and children. So that we can assess that they have
adapted those practices for their life time.

Phase V- Data analysis and report writing

After intervention, the assessment of data will be done. The responses in the questionnaires will
be entered and analysis will be done. The data will be expressed in percentages, Annova test
will be used to calculate results. SPSS will be used for data analysis. The level of significance
will be considered at p value<0.05.

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